Winnicott and the therapeutic community


The Therapeutic Community



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The Therapeutic Community

Winnicott’s concepts, like any good theory, help make sense out of the events of daily clinical experience, and therefore are themselves a holding, coherence-gathering environment. I want to suggest further that a residential treatment setting may provide through its various disciplines - psychotherapy, nursing, activities, administration, etc. - a range of environmental provisions to meet and facilitate the early developmental processes Winnicott was so articulate about. With these provisions, problematic object relationships may be played out in a relatively safe social environment. This both distributes the transference, making the weight of unbearable affect more survivable, and it creates the possibility of putting into words the unarticulated but highly charged object-relations of the patient’s past life.


Before this drama can be played out, however, the patient’s capacities to be and be with must be established, and the collective strengths of the community must be developed such that they might anchor a durable social milieu capable of containing regressive moments. Winnicott (1945) spoke of holding, handling and object-presenting (and later survival) as the environmental provisions necessary to the basic developments of integration, personalization and object-relating (and later object usage) respectively. The quite ordinary, reliable attentiveness of nursing staff, for example, may become the extraordinary provision of “being there at the right time.” The craft studio becomes a space in which to register the developing self over time, which is a holding function, or to use the medium of materials for tentative self-other engagement (Milner, 1957). The psychopharmacologist, in how he talks to a patient about medication, handles, in Winnicott’s terms, the relation between self and body. And so on. I do not mean to suggest here a simple schematic such that, for example, personalization is achieved through the ministrations of a particular department, but rather that these and other daily, accumulating, differentiated provisions from all staff to patients represent symbolic equivalents of those early developmental processes that facilitate the re-establishment of a unit self in a context of others. Conceptualizing these provisions helps us notice the crucial developmental issues - and their fate - with which any given patient is struggling.
The therapeutic community enlarges the context of others to include patients as well as all the staff. As a form of psychological treatment, however, it has become increasingly rare in America, along with hospital treatment itself, in the current emphasis on management, financial constraint and a narrow view of productivity. The promise and the learning beginning in that heady post-war era of Maxwell Jones (1953), Thomas Main (1946), Karl Menninger (1936-37) and Marshall Edelson (1970) survive now only in a handful of programs, which rarely come to the attention of today’s beleaguered individual practitioners.
And yet all around us we hear about community: community homes for the de-institutionalized patient, strange communities as millennial havens for society’s dispossessed, community policing as a major factor in reducing crime rates, community cohesion as distinguishing safe neighborhoods from unsafe ones, regardless of poverty level, community affiliations as providing a form of social capital to the democratic process. Indeed, community may be an antidote to the social and perhaps even the structural ailments associated with 21st century capitalism: namely, the intrapsychic and inter-generational conflicts associated with greed and envy, the ensuing deprivation of others, including family members, and the effect on superego development, both in terms of conscience and ego ideal.
For seriously disturbed patients, a therapeutic community program, enriched by a psychodynamic systems perspective, can provide an essential holding environment for treatment as well as a remarkable depth of learning in itself. At the beginning of this therapeutic community’s psychoanalytic history, when burgeoning crises with patients were making it clear to senior staff that analytic neutrality was no way to administer a hospital, a “historic decision” was taken “to talk the situation over with the patients” (Christie, 1964, p.458). This “talking it over with the patients” became the core of the program. It represents a serious partnership between patients and staff of mutual problem solving and examined living.
Begun in the early 1950’s as part of an international movement toward the creation of intentional restorative communities for the treatment of psychiatric patients, this therapeutic community thrived initially on principles related to the ego psychology of the day: the importance of the patients’ strengths or conflict-free sphere of ego functioning, the neutralization of aggression through real tasks and real interaction with people, the importance of social learning, the power of multiple roles to forestall pathological identity foreclosure, and the importance of sublimation through creativity. Winnicott was an ego psychologist as much as he was an object-relations theorist (Fromm, 1989a), and many of his developmental interests and conceptual discoveries parallel and coincide with those of Erik Erikson during the ten years the latter theorist was associated with this program.
In an open setting, the therapeutic community holds by drawing in rather than by holding apart, relying upon each patient’s wish, however conflicted or split off, to belong and to develop rewarding relationships. It is a play-space or potential space (Winnicott, 1971e; Fromm, 2009), like Winnicott’s room, set off but not sealed off from the world outside the hospital. Within it, patients may play out both the problematic aspects of their personality development and emerging capacities as well.
In this process, projective dynamics inevitably occur; hence the importance of considering symptomatic eruption in group and systemic terms. Acting out by any member of the community not only affects the total community (which is important in its own right); it may also represent something for everyone, something dissociated from conscious dialogue and yet central to understanding the group’s having gotten off-task in some way. Acting out interpreted in terms of the system restores the holding environment it simultaneously tests (Shapiro and Carr, 1991). This perspective may lead to powerful learning in the here-and-now about the community. It may also lead to powerful learning for the patient (or sometimes for the staff member) who may be carrying an issue for the group, with whatever degree of personal distress and compromised functioning. The therapeutic community could be thought of as an “interpretive democracy”, oriented toward finding the meaning within every instance of dissociated unconscious citizenship (Fromm, 2000).
This point of view simply enlarges upon the concept of therapeutic action in “Clinical Varieties of Transference” (1955-56), in which Winnicott describes an essential irony in the therapeutic process: reliability of the therapeutic situation brings about the patient’s vulnerability to failures in holding, specific failures felt very personally because they echo and open up for examination the early environmental failures of childhood. Such failures in the present, owned and interpreted by the analyst, felt with anger that makes sense by the patient, not only restore, but strengthen, the holding environment while they also deepen an understanding of the patient’s total life.
This particular therapeutic community program is actualized in a series of inter-related small and large groups, the hub of which is the daily Community Meeting, chaired by a patient who is elected for an eight-week term by the patient community. Some of the small groups are task-focused, representing an aspect of the community’s functioning (for example, recreation or integrating new members) for which the patient community has accepted responsibility, given its primary interest in and greater ability for these tasks. Other groups take up supportive-reflective tasks; for example, a group of patients vulnerable to substance abuse gathers regularly to support member sobriety and reflect upon the factors within the social environment that might bring about relapse. Moving through the daily life of the community, individual patients not only play out the troubling and unarticulated parts of their personalities, but they also play at the intersection between these troubles and the larger organizational dynamic.



  1. Clinical Sketches


A.
One evening, the community’s chef was leaving after working late and noticed in a dark corner of the parking lot a car with the motor running. A patient had rigged a hose to her exhaust pipe and was seriously considering suicide. The chef intervened and walked her to the nurses. The next day, most of the agenda of the Community Meeting was set aside to talk with this patient. She reported “what happened to her”, a language which the group defensively joined until a staff consultant commented on the process and re-framed the patient’s statement in active terms. Language speaks us more than we speak it; in his comment, the consultant was holding the patient’s agency and aggression, while she was inviting the group to join her in disavowing it. A more real discussion ensued. The patient community was upset, moved and angry at this patient. Her behavior affected them, from their deep recognition of how traumatic an actual suicide would be, to their admiration for this particular patient’s struggles through past suffering, to their upset that this well-liked and thoroughly enjoyed chef might choose not to deal with this kind of stress any longer.

In the course of the discussion, the group’s knowledge of this patient led to a reconstruction of the events prior to her action: her insurance company had recently said to her, in effect, “Get going; other people need these dollars.” Also, her therapist was away attending to his new baby. Finally, just prior to her gesture, she had asked a staff member (though she had turned down other patients) to meet with her because of her distress. The staff member asked her to wait while she finished the admission work for a new patient. From this coherence-gathering dialogue, itself a holding function, a theme emerged clearly: the patient felt bumped aside by new people - displaced, abandoned and angry.

This gathering awareness of the context of her action served to seed this patient’s psychotherapy with potential for deeper analysis of her early life experiences and the transference. There was more to the issue, however, at the level of the group. It turned out that the agenda item that was set aside for this discussion had to do with the Sponsors Group, a patient-led group whose task is bringing new members into the community in a welcoming and orienting way. The Sponsors Chairperson had planned to confront the patient community with, and lead a discussion about, its recent reluctance to sponsor new patients.
In other words, the patient’s angry caricaturing of being disposable in the face of new patients and new children occurred in a context of, and might well have reflected, the group’s angry wish to reject those new faces too. When this discussion was eventually taken up, the group recognized that rejecting new patients was really a way of rejecting the changes they felt the treatment setting to be undergoing as it tried to adapt to a newer, financially driven reality of more patients being admitted for shorter lengths of stay. While the group was calling the patient back to conscious citizenship, it was also recognizing her action as already reflecting a kind of unconscious citizenship (Fromm, 2000) in the sense of its unconsciously representative nature as a protest against unwanted change. Further, once this dynamic became clear, the staff took more seriously the community’s problems with rapid admissions as well as its own contribution to this enactment. Each of these levels of understanding constitutes a deeper level of holding for the individual patient and for the community.





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